Assessing the knowledge of emergency medical care personnel in the Free State, South Africa, on aspects of paediatric pre-hospital emergency care

Introduction In South Africa in 2016, injuries accounted for 4 483 deaths of children aged 0-4 years. Prior studies have reported that, in some parts of the country, poor pre-hospital clinical care is a key contributor to the morbidity and mortality of critically ill and injured children. A key component of a coordinated emergency health care system are emergency medical care (EMC) personnel. Here, we assess the knowledge of EMC personnel employed by the Free State Department of Health on aspects of paediatric pre-hospital emergency care. Methods This descriptive study used a questionnaire survey to obtain data on the knowledge of Free State EMC personnel on aspects of paediatric pre-hospital emergency care. Results Only 197 of the initial 250 questionnaires distributed were returned, giving a response rate of 78.8%. More than half (51.2%) of the participants across the five districts had inadequate knowledge of paediatric pre-hospital emergency care. The majority of EMC personnel could not calculate the paediatric blood pressure for age and did not know the paediatric Glasgow Coma Scale (74.0% and 53.4% respectively; P < 0.0001 in both cases). Participants attributed inadequate knowledge to limited exposure to paediatrics cases, insufficient training, limited scope of practice, and lack of equipment. Conclusion Enhancing the knowledge and skills of EMC personnel in paediatrics pre-hospital care through a short learning programme or continuous professional development programme, and providing adequate paediatric emergency equipment, will ensure that comprehensive pre-hospital emergency care is given to paediatric patients in the province.


Introduction
Accidental life-threatening injuries are among the leading causes of child morbidity (90%) and mortality worldwide [1]. According to a World Health Organization report, injuries and violence account for about 950 000 deaths of children and young people under the age of 18 years each year [1]. Additionally, the childhood injury rate has been reported to be highest in Africa and South Asia [2], with an annual prevalence of 68.2% among 13 to 15 year-olds in six African countries [3]. While prevention is key to reducing death and morbidity caused by life-threatening injuries, providing effective prehospital care promptly can, in most cases, curtail the consequences of a life-threatening injury [4]. A coordinated emergency health care system is essential for ensuring proper, effective and timely interventions to prevent mortality [5,6]. A key component of an emergency health care system is emergency medical care (EMC) personnel who are specialist trained in essential components of a robust acute care system [7].
In South Africa in 2016, injuries accounted for 4,483 deaths of children aged 0-4 years [8]. Since these injuries are often incurred by healthy children who are engaging in daily activities, the injuries can be particularly devastating to the injured child and their families, and may have tragic short or long-term consequences [9].
In a cohort study of critically ill and injured children performed in Cape Town, Hodkinson et al. report that delays by the emergency medical services system and poor pre-hospital clinical care are key contributors to the morbidity and mortality of critically ill and injured children [6]. In the Free State province of South Africa, approximately 1 500 EMC personnel are employed across the five districts of the province (Xhariep, Motheo, Fezile Dabi, Lejweleputswa, and Thabo Mofutsanyane). For this present study, we used a questionnaire survey to assess the knowledge of the EMC personnel employed by the Free State Department of Health (DoH) on aspects of paediatric pre-hospital emergency care.

Methods
This research was designed as a descriptive study that made use of a questionnaire survey.
Questionnaire survey: The structured questionnaire used in this study was self-administered and was distributed manually (in hard copy) to the participants during two contact sessions organised for the purpose of this study. The questionnaire was compiled using factors, identified during the literature review, which had been used by previous studies. Some questions were adapted so that they were applicable to the context of the pre-hospital EMC environment.
The questionnaire collected data in the following three sections: Section A: Biographical data: gender, age, race, qualification, district of operation, level of experience, postgraduate qualifications, Section B: Knowledge of participants in relation to aspects of paediatrics pre-hospital emergency care, Section C: Open-ended questions requested participants to suggest how paediatric pre-hospital emergency care can be improved in the province.
Assessing the knowledge of EMC personnel on aspects of paediatrics pre-hospital emergency care: in order to assess participants' knowledge on aspects of paediatric pre-hospital emergency care, Section B asked participants to provide written answers to seven subject-specific questions relating to aspects of paediatrics emergency care in the pre-hospital setting. The levels of knowledge assessed include, Level 1: Remember (K1) (The ability of participants to recognise, remember and recall terms or concepts); and Level 2: Understand (K2) (The ability of participants to explain ideas or concepts) [10]. The correct answers to the questions used in the questionnaire were sourced from textbooks and national and international standard guides. The correct answers were given to an independent assistant, who marked participants written answers.
The independent assistant is a qualified EMC practitioner who is trained in providing pre-hospital emergency care to paediatric patients. One of the researchers, who is a qualified EMC practitioner who has also received training to provide paediatrics pre-hospital emergency care, later crosschecked participants written answers and scores. Participants responses were grouped into correct, incorrect and uncertain (participants did not provide a correct answer, instead, gave incomplete explanations).

Results
Only 197 of the initial 250 questionnaires that had been distributed were returned, giving a response rate of 78.8%.  Figure 1).

Desire to obtain further qualification/training in EMC:
The majority (92%) of participants indicated a desire to obtain further qualifications/training in pre-hospital emergency care, while 3% said they did not. Of the participants, 5% did not answer the question (n = 187). The reasons given by those who desire to obtain further qualifications/training in EMC are summarised and presented as themes and categories in Table 1.

Number of years post qualification:
The majority (34.0%) of participants had obtained their qualification in the last five years, while only 5.0% had obtained their qualification more than 21 years ago. A further 30.0% and 24.0% of the participants are 6-10 and 11-20 years post qualification, respectively. Seven percent (7%) did not provide information in response to the question ( Figure 2).

Duration of service:
The number of years that participants had been working as pre-hospital emergency medical care personnel is presented in Figure 3. The majority, that is, 36.0% of participants, indicated that they had been in service for between one and five years. A further 32.0% had worked for 6-10 years, while only 2.0% had less than a year of service ( Figure 3). Nine participants (4%) indicated "No response". care and transport this kinds of patient and I attended the PALS training", #2 "I did a module in paediatric care and transportation", #3 "Because even now I am still in training", #4 "Because I am currently busy with my obstetrics classes", #5 "Due to constant inservice training programmes run in the district", #6 "Workshops regarding paediatrics were rendered", #7 "We are working with so many paediatrics, I gained experience", #8 "Because I've never been exposed to paediatric cases most of the time", #9 "Need more training on paediatrics", #10 "People don't know how to treat paediatric-only take temperature", #11 "I do not have enough training on paediatric patients", #12 "I am not trained", #13 "Limited scope of practice", #14 "My qualification does not allow me to treat paediatric", #15 "I don't get enough education and training for paediatric prehospital care", #16 "Because I can only treat to a certain point-it is my protocol", #17 "Because we don't have equipment for paediatric on the ambulance", #18 "Because of some lack of information" Participants knowledge on aspects of paediatrics prehospital emergency care: Table 3

Discussion
Pre-hospital emergency medical personnel respond to and manage diverse urgent medical situations, including paediatrics emergencies.
Children account for 10% of EMC incidents [11] and their prehospital emergency needs differ greatly from that of adult patients [12]. Noteworthy is that the pattern of paediatrics emergencies may vary regarding location (rural or urban) [13], gender, and age category [14], season of the year, day of the week, and time of call  [11]. The lack of equipment reported by participants of this study confirms these findings by Anest et al. (2016), who, in their Cape Town study, report that lack of paediatric-specific equipment, such as incubators, appropriate blood pressure cuffs and ventilators with paediatric settings, constitute a major barrier to pre-hospital care of paediatric patients [18].  (Table 3). The GCS score is the most commonly tool used to assess the severity of traumatic brain injury in both adults and children [32] and has been reported to be the most feasible, accessible and reliable predictor of traumatic brain injury outcome in paediatrics [33].

Acknowledgments
The researchers wish to thank all EMC personnel of the Free State DoH who participated in this study.